AHIP 2023
Mr. Sanchez has just turned 65 and is entitled to Part A but has not enrolled in Part B because he has coverage through an employer plan. If he wants to enroll in a
Medicare Advantage plan, what will he have to do? Correct Answer: He will have
to enroll in Part B.
Mrs. Walters is enrolled in her state's Medicaid program in addition to Medicare.What should she be aware of when considering enrollment in a Medicare
Advantage (MA) plan? Correct Answer: She cannot enroll in an MA Medical
Savings Account (MSA) plan.
Mr. Gomez notes that a Private Fee-for-Service (PFFS) plan available in his area has an attractive premium. He wants to know if he must use doctors in a network as his current HMO plan requires him to do. What should you tell him? Correct
Answer: He may receive health care services from any doctor allowed to bill
Medicare, as long as he shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing.
Ms. Gibson recently lost her employer group health and drug coverage and now she wants to enroll in a PPO that does not include drug coverage. What should you
tell her about obtaining drug coverage? Correct Answer: She can enroll in the
PPO, but she will not be able to purchase a stand-alone Medicare Part D prescription drug plan.
Mrs. Kelly, age 65, is entitled to Part A but has not yet enrolled in Part B. She is considering enrollment in a Medicare Advantage plan (Part C). What should you advise her to do before she will be able to enroll in a Medicare Advantage plan?
Correct Answer: To join a Medicare Advantage plan, she also must enroll in Part
B.
Mrs. Andrews asked how a Private Fee-for-Service (PFFS) plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her? Correct Answer: Medicaid may provide 1 / 3
additional benefits, but Medicaid will only pay for these services if they are furnished by Medicaid participating providers.
Mr. Kumar is considering a Medicare Advantage HMO and has questions about his
ability to access providers. What should you tell him? Correct Answer: In most
Medicare Advantage HMOs, Mr. Kumar must generally obtain his services only from providers within the plan's network (except in an emergency or where care is unavailable within the network).
Juan Perez, who is turning age 65 next month, intends to work for several more years at Smallcap, Incorporated. Smallcap has a workforce of 15 employees and offers employer-sponsored healthcare coverage. Juan is a naturalized citizen and has contributed to the Medicare system for over 20 years. Juan asks you if he will be entitled to Medicare and if he enrolls how that will impact his employer-
sponsored healthcare coverage. How would you respond? Correct Answer: Juan is
likely to be eligible for Medicare once he turns age 65 and if he enrolls Medicare would become the primary payor of his healthcare claims and Smallcap does not have to continue to offer him coverage comparable to those under age 65 under its employer-sponsored group health plan.
Dr. Elizabeth Brennan does not contract with the ABC PFFS plan but accepts the plan's terms and conditions for payment. Mary Rodgers sees Dr. Brennan for
treatment. How much may Dr. Brennan charge? Correct Answer: Dr. Brennan can
charge Mary Rogers no more than the cost sharing specified in the PFFS plan's terms and condition of payment which may include balance billing up to 15%of the Medicare rate.
Daniel is a middle-income Medicare beneficiary. He has chronic bronchitis, putting him at severe risk for pneumonia. Otherwise, he has no problems functioning.
Which type of SNP is likely to be most appropriate for him? Correct Answer: C-
SNP
Mr. Lombardi is interested in a Medicare Advantage (MA) PPO plan that you represent. It is one of three plans operated by the same organization in Mr.Lombardi's area. The MA PPO plan does not include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare prescription drug plan. What should you tell him about this situation? Correct
Answer: He could enroll either in one of the MA plans that include prescription
drug coverage or Original Medicare with a Medigap plan and standalone Part D 2 / 3
prescription drug coverage, but he cannot enroll in the MA-only PPO plan and a stand-alone prescription drug plan.
Mr. Romero is 64, retiring soon, and considering enrollment in his employer- sponsored retiree group health plan that includes drug coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and because he takes numerous prescription drugs, he is considering signing up for it. What
should you tell him? Correct Answer: He should compare the benefits in his
employer-sponsored retiree group health plan with the benefits in his neighbor's MA-PD plan to determine which one will provide sufficient coverage for his prescription needs.
Mrs. Lyons is in good health, uses a single prescription, and lives independently in her own home. She is attracted by the idea of maintaining control over a Medical Savings Account (MSA) but is not sure if the plan associated with the account will fit her needs. What specific piece of information about a Medicare MSA plan would it be important for her to know, prior to enrolling in such a plan? Correct
Answer: All MSAs cover Part A and Part B benefits, but not Part D prescription
drug benefits, which could be obtained by also enrolling in a separate prescription drug plan.
Mr. Sinclair has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about Medicare Advantage Special Needs Plans (SNPs). What could you tell him?
Correct Answer: SNPs have special programs for enrollees with chronic
conditions, like Mr. Sinclair, and they provide prescription drug coverage that could be very helpful as well.
Mrs. Willard wants to know generally how the benefits under Original Medicare might compare to the benefits package of a Medicare Advantage Plan before she
starts looking at specific plans. What could you tell her? Correct Answer:
Medicare Advantage Plans may offer extra benefits that Original Medicare does not offer such as vision, hearing, and dental services and must include a maximum out-of-pocket limit on Part A and Part B services.
Mrs. Chi is age 75 and enjoys a comfortable but not extremely high-income level.She wishes to enroll in a MA MSA plan that she heard about from her neighbor.She also wants to have prescription drug coverage since her doctor recently prescribed several expensive medications. Currently, she is enrolled in Original Medicare and a standalone Part D plan. How would you advise Mrs. Chi? Correct
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